LIFE MED HISS: The Four Participant Countries

National interview survey (e.g. ItalyItalyItalyItaly)

“Health and healthcare utilization” (1999-2000)

Record linkage with the health data

National

survey

(nominative

data)

Key linkage

IndividualIndividualIndividualIndividual fiscal codefiscal codefiscal codefiscal code

Surname, name, birthdate,

gender and town of birth

Mortality data

(2000 - 2012)

Morbidity data

(2001 - 2008)

Italy: 128,818 subjects linked with the health data

MethodsThe proposed approach is based on the availability of 3 sources ofdata:1) National Health Interview Surveys (NHIS), available in all

EU countries, representative of total population and coveringboth urban and rural areas;

2) Mortality and hospital admissions registries and3) Air pollution models at high resolution level.The original idea of the project was to follow-up participants inthe health surveys linking them with mortality and morbidity dataregisters. NHIS usually includes individual information on mainpotential confounders for air pollution (smoking, BMI, occupation,education etc).

ResultsThe MED HISS project has demonstrated the feasibility of the proposedapproach.The use of already available surveys at individual level reduces the highcost of recruiting and interviewing a large cohort.Record-Linkage procedures are quick and not very expensive.The wide availability of air pollution models reduce also the cost of theexposure assessment phase.In Italy the project showed associations in line to those reported in theliterature. The Relative risk of mortality for 10 µg/m3 of PM2.5 calculated inthe Italian cohort for All Natural causes was 1.04 (1.02-1.06) while lastWHO review (REVIIHAP Project) reported a metanalytical RR of 1.06(1.04-1.09), which is not statistically different.

Restrictive privacy policies, arisen in Spain and Slovenia after the start ofthe project, didn’t allow the individual linkage between NHIS sampledsubjects and mortality/morbidity data.An ecological approach was set up as alternative study design based on1) Variables at municipal level (%smokers, % obese, % unemployed etc)2) Air pollution models at municipal level3) RR calculation for each pollutant with multiple regressionThe results of this approach, even if showing a positive correlation of manycauses with air pollution, are less precise than those obtained with theindividual approach.

Ennio Cadum (1), Maria Rowinski (1), Giovanna Berti (1), Xavier Basagaña (2), Luisella Ciancarella (3), Teresa Spadea (4), Isabella Annesi-Maesano (5,6), Peter Otorepec (7), Gabriele Zanini (3), Giuseppe Costa (4)

on behalf of the LIFE MED HISS collaborative Group*

1. Environmental Epidemiologic Unit, Regional Agency for Environmental Protection, Piedmont Region, Torino, Italy2. Barcelona Institute for Global Health (ISGLobal) - Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain3. ENEA Italian National Agency for New Tecnologies, Energy and Sustainable Economic Development, Bologna, Italy4. Epidemiology Unit, ASL TO3, Piedmont Region, Torino, Italy5. Epidemiology of Allergic and Respiratory Diseases Department (EPAR), INSERM, Paris, France6. Université Pierre et Marie Curie, Paris, France7. National Institute of Public Health, Ljubljana, Slovenia Corresponding author: ennio.cadum@arpa.piemonte.it

IntroductionIs it possible to set up a surveillance system for long term effects ofair pollution? LIFE MED HISS is a EU LIFE Pilot project involving fourcountries (Italy, France, Slovenia and Spain) aiming to answer to thisquestion, that require low-costly approaches.A quantification of air pollution effects in Europe is needed along withits variation in time to support European policies in the field“Environment & Health”.

ConclusionsThe project has demonstrated that it’s possible to set up asurveillance system even for long term effects of air pollution inEurope.This approach requires preferably to homogenize anonymisationand linkage procedures at individual level and to standardize NHISquestionnaires across Europe.The project showed that when linkage is possible, existingresources can be used to obtain results that are comparable tothose obtained in large expensive cohort studies.Therefore, this approach could become very useful for publichealth surveillance purposes.

LIFE MED HISS - LIFE12 ENV/IT/000834: An “health surveillance” pilot project on long term effects exposure to air pollution

to implement an European system

Air pollution maps can be used to assign air pollution exposureto survey participants based at least on municipality of residence.Air pollution predictions at a 4x4 km2 resolution can be integratedwith measured levels and up-scaled at municipal level.

*LIFE MED HISS Collaborative Group: Italy: S. Bande, G. Berti, G. Briganti, E.Cadum, A. Cappelletti, P. Carnà, L. Ciancarella, G. Cremona, M. Clemente, G.Costa, M. Demaria, R. De Maria, E. Ferracin, M. Gandini, S. Ghigo, R. Gnavi, M.Grosa, M. Mircea, R. Onorati, A. Piersanti, G. Righini, M. Rowinski, C. Scarinzi, T.Spadea, G. Zanini; France: N. Baïz, S. Banerjee, JF. Bertholon, A. Fouad, C.Maesano, AM. Magnier, S. Launois, I. Annesi-Maesano, A. Moustafa, S. Sanyal;Slovenia: K. Bitenc, I. Erzen, T. Grča, A. Kukec, P. Otorepec, M. Rus, L. Zaletel-Krageli; Spain: D. Agis, G. Arévalo, J. M Baldasano, J. Barrera-Gómez, X.Basagaña, J. Benach, È. Martinez-Solanas.

The research described was conducted under

the grant agreement European Commission,

DG Environment, LIFE12 ENV/IT/000834

NO2 Maps at gridded level (left) and at municipal level (right) in Spain, 2013

% employed by municipality, PM2.5 at municipal level, SMR for Resp. causesin Slovenia, 2011 2011 2013 (m. regression)

As a consequence of the project, in Slovenia the procedures for usingindividual nominative health survey data were changed and nowallow future linkages with other data, like mortality, natality orhospital admissions.

France: result of CHIMERE model for PM10, winter 2012